From every perspective, life is to be enjoyed. We collectively and privately define the quality of that experience differently, but everyone values health and would prefer to avoid disease if possible, even in exchange for longevity. Who would want to be a millionaire if the deal came with severe disease associated with persistent pain and death within a year?
We have made great strides in the past 50 years to make good health a reasonable expectation for most people. Both cardiovascular disease and type 2 diabetes, as well as their complications, mostly are preventable, especially in those under age 65. The prevention of cardiovascular disease and type 2 diabetes depends on three key factors: 1) the identification of those most susceptible to risk factors; 2) the identification of the risk factors, and 3) modifications of the risk factors. This last component is a function of both pharmacological and non-pharmacological therapies and long-term adherence to such therapies.
Regrettably, there is a disconnect between the science and logic of these universally accepted goals of wellness and risk reduction and the practical realities of lifestyle and access to health care. Our nation is experiencing a contradictory approach to health that often focuses on epiphenomena, low-benefit/high-profile activities and unproven initiatives. In collaboration with UPMC Health Plan, Pitt is initiating programs to improve the overall quality of the health of faculty, staff and their families. These initiatives and the debate surrounding effective programs form the substrate for the University Senate fall plenary session entitled “Embracing Fitness for Life,” to be held at 2 p.m. Oct. 17 in the William Pitt Union Assembly Room.
Important epidemiological facts relate to the implementation of such programs. Although most efforts to prevent cardiovascular disease currently are aimed at those who are at highest risk, most heart attacks occur in those whose risk scores fall in the 20th-80th percentile range, which represents 60 percent of the population. Thus, our focus needs to be broadened. In addition, due to poor diet and lack of exercise we are experiencing an epidemic of obesity that crosses all socio-economic boundaries. Approximately 54 million people in the United States have pre-diabetes, a condition in which higher-than-normal blood glucose levels may inconspicuously be causing long-term cardiovascular damage. Successful prevention of cardiovascular disease and type 2 diabetes is a long-term commitment that should begin early. The longer one delays primary prevention, the lower the overall success rate in terms of actual reduction in risk (although absolute risk reduction goes up with age mainly because the absolute risk of disease increases with age).
Unfortunately, identification of risk factors is insufficient without programs that maximize risk factor reduction in terms of long-term adherence to therapy. Furthermore, non-pharmacological interventions, such as dietary intervention, increasing physical activity or weight loss, often are difficult to maintain. Substantial reduction of low-density lipoprotein/cholesterol by dietary interventions requires very aggressive intervention programs managed by nutritionists, behavioral interventionists, etc. Such programs are effective for a limited number of participants but are relatively expensive to maintain. Short-term dietary interventions to reduce lipid levels or obesity usually are unsuccessful. Thus, the stage is set for a partnership between employer, health plan and member to create an environment and programs that promote wellness and cardiovascular disease/type 2 diabetes risk reduction. At Pitt this program is called Fitness for Life.
But several uncertainties exist. Since health maintenance programs are not free and resources are limited, how the University uses these resources is of significant importance to the overall health of the faculty and staff. Several prominent health care economists have said that good health is cost-neutral because the increased cost of wellness programs and risk management systems is offset by reduced health care costs of hospitalizations and chronic disease management and improved productivity from a healthier and happier workforce. Though inspiring as a concept, there are no good means of proving the cost-effectiveness of such programs. We do know, however, that health and a healthy lifestyle are essential to maximize the quality of life.
The critical questions are: 1) How can we identify those individuals who are most susceptible despite sub-threshold risk factor levels? Data collected in multiple longitudinal observational studies demonstrate that this is best accomplished by identifying the presence of “sub-clinical” vascular disease. 2) Once one identifies an at-risk person, what is the appropriate time for drug therapy versus continued follow-up or lifestyle modification? 3) Among lifestyle modifications, what is the appropriate time for more expensive lifestyle modifications, i.e., structured weight loss, increasing exercise, reducing lipoprotein levels, smoking cessation and stress reduction programs? 4) How does one identify the non-adherent population? Once we have a better understanding of the answers, together as a University community we need to fashion them into tangible programs as the Fitness for Life program evolves.
Michael R. Pinsky, professor of critical care medicine, is chairman of the Senate’s Fitness for Life ad hoc committee.